Endonasal Ethmoidectomy and Bifrontal Craniotomy with Craniofacial Approach for Resection of Frontoethmoidal Osteoma Causing Tension Pneumocephalus

Tension pneumocephalus is an unusual, potentially life-threatening complication of frontal fossa tumors. We present an uncommon case of a frontoethmoidal osteoma causing a tension pneumocephalus and neurological deterioration prompting a combined endonasal ethmoidectomy and bifrontal craniotomy with craniofacial approach for resection. A 68-year-old man presented with a 1-week history of worsening headache, slowness of speech, and increasing confusion. Standard computed tomography scan revealed a marked tension pneumocephalus with ventricular air and 1-cm midline shift to the right. Further studies showed a calcified left ethmoid mass and a left anterior cranial-base defect. A team composed of neurosurgery and otolaryngology performed a combined endonasal ethmoidectomy and bifrontal craniotomy with craniofacial approach to resect a large frontoethmoid bony tumor. No abscess or mucocele was identified. The skull base defect was repaired with the aid of a transnasal endoscopy, a titanium mesh, and a pedunculated pericranial flap. Postoperatively, the pneumocephalus and the patient's symptoms completely resolved. Pathology was consistent with a benign osteoma. This is an uncommon case of a frontoethmoidal osteoma associated with tension pneumocephalus. Recognition of this entity and timely diagnosis and treatment, consisting of an endonasal ethmoidectomy and a bifrontal craniotomy with craniofacial approach, may prevent potential life-threatening complications.     

Noninvasive assessment of microcirculation of living organs and tissues using laser

For studying microcirculation of intact tissues or organs, a new noninvasive, heat-transient method using laser photoexcitation is described. As a heating source an argon ion laser or R6G dye laser was used via a quartz fiber optic guide. Infrared radiation from heated tissue was detected by a thermography apparatus. After switching the laser irradiation on and off, a thermal transient curve of a model tissue, the skin, was biphasic: a component with a fast time constant and the other with a slow time constant. The temperature increases of both phases following laser irradiation were linear to the applied power from the laser onto the tissue. The temperature rises as a function of the wavelength of irradiated light have shown that the absorption of the light by tissue hemoglobin is a main heat-generation source. Furthermore, the temperature rises as a function of tissue blood volume and flow have shown that the component with a slow time constant is more related to the tissue hemoglobin concentration and tissue blood flow and heat conductivity. Thus, the analysis of heat-transient curves following laser irradiation gives information as to regional tissue blood volume, blood flow, and tissue heat conductivity.     

Intraluminal approach for resection of a gastric ulcer: a case report.

Laparoscopy, both diagnostic and therapeutic, has been used in the management of gastric pathology because of all the benefits of a minimally invasive procedure, such as faster recovery, shorter hospital stay, fewer wound complications, and other benefits. We report a case involving the resection of a gastric ulcer in a 71-year-old patient. Endoscopy revealed a nonhealing antral ulcer that was not acutely bleeding. With a combined endoscopic and laparoscopic approach, we successfully performed a wide resection by using 2-mm instruments. Laparoscopy was needed to orient the lesion so that a transgastric intraluminal resection could be performed with 2-mm instruments. This case illustrates the feasibility of using a combined endoscopic and laparoscopic technique to treat a lesion that would otherwise require a formal resection.     

Headache due to an osteochondroma of the axis

We reported a case of a 42-year-old man with a 3-year history of headache due to a spinal osteochondroma. Repeated neurological evaluation, including EEG studies and CT of the cerebrum, revealed no pathology. More recently the patient presented with persistent headache and a slight limitation of neck motion. MRI studies of the cerebrum including the cervical spine showed a high cervical extradural tumor. Additional CT angiography showed a bony tumor suspected of being a spinal osteochondroma. An en bloc resection of the tumor was performed; histological evaluation confirmed the diagnosis. Immediately after intervention, all symptoms disappeared. In most patients with a spinal osteochondroma, the lesion causes no symptoms, or symptoms are aspecific. Therefore, there is often a significant delay between initial complaints and the diagnosis, as in the current case.     

Prevention of parastomal hernia by the placement of a mesh at the primary operation

Introduction  Parastomal hernia is a well known clinical problem, and up to 50% of all patients having a stoma will eventually develop a parastomal hernia. There are many surgical options available for the repair of a parastomal hernia, but the prevention of hernia development has only recently received scientific attention. The most encouraging results have included the use of a mesh inserted at the primary operation. We have, therefore, chosen to review the literature regarding the results of operative techniques, including mesh placement, for the prevention of a parastomal hernia. Materials  We performed a systematic literature search and found five publications which, in total, included 112 patients having a prophylactic mesh during their stoma formation. One study was a randomized controlled trial which included 54 patients, of which, 21 patients had a prophylactic mesh. The remaining four studies were prospective observational series. Results  Three of the 112 patients had a hernia recurrence within the follow-up period, which ranged from 2 to 48 months. One of the 52 patients that had a sublay mesh placed at the primary operation and two of 60 patients that had an onlay mesh developed a hernia. There were no infections or other serious complications related to the mesh in any of the studies. Conclusion  The results of placing a prophylactic mesh when performing a permanent stoma in the elective situation are very promising. However, the data are preliminary and with relatively short follow-up times. Therefore, it should be confirmed in larger, double-blinded, controlled randomized clinical trials whether there are short- and long-term advantages of placing a mesh at the primary operation, and where the mesh should be placed in the abdominal wall.     

Repair of Left Ventricular Assist Device Driveline Damage Directly at the Transcutaneous Exit Site

With increasing support duration of cardiac assist devices, transcutaneous drivelines remain a weak point of the therapy. First, they can be an entry point for infections, and second, cable lesions and even electrical failures due to material fatigue and eventual carelessness can occur. We report a case of a damaged outer sheath of a ventricular assist device driveline cable directly at the exit site, where the standard repair procedure with self‐fusing tape may lead to biocompatibility problems and irritation of the entrance through the skin. Therefore, a new procedure was developed using a special sleeve expander tool and a highly expandable latex tubing to stabilize the defect in a flexible and biocompatible manner. A patient experienced a fracture of the outer sheath of a HeartWare HVAD driveline directly at the skin entrance (approximately 15 mm long, 5 mm distal from the skin). The metal strands and the electrical functionality were yet not affected, therefore, a pump exchange was not indicated. After considering several conventional solutions for repair as not applicable, a new approach was developed: a sleeve expander tool was applied, which allowed radial stretching of the latex tubing. After preparations of the tool and the cable site, the pump was briefly disconnected, the tubing was moved over the connector and was released at the site of fracture. The problem could be solved by keeping the cable's flexibility and without additional risks to the skin. Within a still ongoing (5‐month) follow‐up, the skin entrance returned to perfect condition and no further intervention was necessary. In conclusion, this method allows a quick stabilization and repair of damaged driveline isolations even near the exit site, resulting in a biocompatible surface and consistent flexibility of the cable.     

Vaginal Leiomyoma – an Imitator of Prolapse

Vaginal leiomyoma is a rare tumor with a variable clinical presentation and broad differential diagnosis that can lead to preoperative misdiagnosis. We present a case of vaginal leiomyoma with a symptom complex of prolapse, urinary urgency and urge incontinence. A 50-year-old woman presented with a 4-year history of deteriorating sensation of prolapse, significant complex urinary complaints and prolonged vaginal bleeding. Clinical examination revealed a mobile 6 × 8 cm mass arising from the anterior vaginal wall. She underwent hysteroscopy, curettage, urethrocystoscopy (normal findings) and mass enucleation through a vertical incision. Histology showed a benign leiomyoma. Ultrasonography, MRI, positive-pressure urethrography and urethrocystoscopy should be considered in the evaluation of an anterior wall vaginal mass. Surgical enucleation via a vaginal approach is the treatment of choice. If this surgical procedure results in skeletonization of the urethral and bladder support, a colporrhaphy/pubourethral ligament plication is required.     

Zero‐order asymptotic solution of a class of singularly perturbed linear‐quadratic problems with weak controls in a critical case

We consider a linear‐quadratic optimal control problem where the second power of a small parameter stands in front of the derivative and a control in a state equation and in front of a quadratic form with respect to control in a performance index; moreover, in the state equation, the nonhomogeneity has the first order of the power of a small parameter, and a matrix in front of the state variable is singular if the small parameter is equal to zero. Using immediate substituting a postulated asymptotic expansion of a solution, containing a regular series and four boundary layer functions series, into the problem condition, we obtain problems for finding asymptotic terms of the zero order for the optimal control and the first order for the optimal trajectory. An illustrative example is given.     

Dentin matrix collagen: Evidence for a covalently linked phosphoprotein attachment

Oxidative degradation of decalcified bovine dentin matrix with alkaline sodium metaperiodate solubilizes a substantial part of the matrix. The soluble portion includes a fraction containing more than 75% of the covalently-bound phosphorus present in the native dentin. Preparative scale electrophoresis of the solubilized dentin on polyacrylamide gels led to the isolation of a group of four strongly anionic components (I–IV). Analyses showed each component to be a protein characterized by a high content of phosphate groups, serine and aspartic acid, and, with one exception (II), small amounts of proline and hydroxyproline. Each component contained one residue of hydroxylysine per mole. In addition to the periodate resistant hydroxylysine, III and IV also contained periodate resistant glucose and galactose. On the basis of the presence of hydroxyproline in varying amount, and hydroxylysine on a mole per mole basis, it is suggested that components I, III and IV consist of collagen backbone fragments linked to a phosphoprotein moiety with a high content of serine and aspartic acid. The periodate-resistant hexoses and the hydroxylysine probably represent the linkage point. Component II is a phosphoprotein moiety essentially free of a collagen fragment. These data provide direct evidence that dentin collagen contains a covalently bound non-collagen polypeptide attachment of highly acidic character.Holder of a Helen Hay Whitney Foundation Post-Doctoral Fellowship during a part of the period during which this work was carried out     

Salvage of a leg avulsion injury by vacuum negative pressure therapy: a case report

We present the case of a 51-year-old woman who suffered an avulsion injury of the right leg in a car accident. In a first time, the simple suture with tiny debridement of the flaps is a failure and lead to a nearly complete necrosis. In a second time, a total avulsion of the devitalized skin is realised and a circumferential VAC system is placed on the wound. Four cycles of vacuum therapy and twelve days later, a split-thickness skin mesh-graft is applied on the leg. This one has a very good take and allows the patient to stand up one month after the initial accident. This example underlines the role of cleaning and pro-budding of the negative therapy after the salvage of a leg avulsion.     

Myogenous sarcoma of the gallbladder with a hemangiopericytomatous pattern

Primary sarcoma of the gallbladder is a very rare neoplasm, and there are few instances of its diagnostic and therapeutic management. We describe a 66-year-old male patient with a sarcoma of the gallbladder. He initially underwent a laparoscopic cholecystectomy, converted to an open procedure. Histology showed a primary sarcoma of the gallbladder (NOS). A relaparotomy, with resection of the cystic stump, anatomical hepatic resection of the fifth segment, including the bed of gallbladder, and lymphadenectomy was performed a few days later. The two surgical interventions were done with no major complications, and a radical resection status was achieved. Histological investigation revealed a malignant mesenchymal tumor lesion, which was classified as a myogenous sarcoma with a hemangiopericytomatous pattern. After an 11-month, uneventful, postoperative course, local tumor recurrence was diagnosed. Palliative chemotherapy was scheduled, but the patient died of advanced tumor recurrence 10 days after this diagnosis. Despite a poor overall prognosis, extensive surgical resection is favored for myogeneous sarcoma of the gallbladder; this procedure is based on precise clarification of the histopathological diagnosis, and can be followed by attempts with radiation of chemotherapy if early diagnosis-finding has failed. This approach allowed, in our patient with this rare neoplasm, a remarkable tumor-free survival of almost 1 year.     

Delayed unrelated presentation of a lumbar burst fracture consequent to a remote episode of a single convulsive seizure: A diagnostic challenge

Non-traumatic vertebral fractures occurring as a sole consequence of the violent muscle forces generated during the first episode of a GTCS(generalized tonic clonic seizure) in a previously healthy non-epileptic individual are very rare. Being clinically asymptomatic they are easily overseen at the time of initial presentation due to their rarity of occurrence and the presence of potentially distracting factors in the post-ictal phase. We present a 52-year-old healthy non-epileptic male who presented with unrelenting back pain and neurodeficit secondary to a four-month-old unstable burst fracture of the first lumbar vertebra sustained during an isolated single episode of a witnessed GTCS. A detailed inquiry revealed no history of a significant traumatic event either during the convulsive episode or thereafter. A meticulous history taking, a thorough clinical and neurological examination combined with a comprehensive radiological evaluation established the unusual etiology of the fracture and the presence of a thoracolumbar kyphotic deformity with compression of conus medullaris. A detailed neurological, and laboratory work-up, confirmed no attributable organic or metabolic cause for the seizure. His BMD(Bone Mineral Density) was normal. Patient was managed with posterior instrumented deformity correction by a posterior column shortening osteotomy, neural decompression and fusion of D12-L1 facets. Patient had complete neurological recovery with good clinical and functional outcomes at 28-months follow-up. A few cases of seizure-induced non-traumatic spinal fractures have been published in literature. A majority of these fractures occurred in individuals with either seizure-provoking risk factors (epileptics with recurrent seizures, brain tumors, drug overdose/withdrawal, metabolic disorders, or electrolyte imbalance) or in those with an increased susceptibility to fracture due to decreased BMD. This case demonstrates the rare occurrence of a non-traumatic vertebral fracture during the first episode of a GTCS in an otherwise healthy non-epileptic individual with normal BMD and no seizure-provoking risk factors. This is the first case report of a delayed unrelated presentation of a non-traumatic lumbar vertebral fracture with complications (spinal deformity and neurodeficit) consequent to a remote episode of a single convulsive seizure. It emphasizes the need for a high index of clinical suspicion,a meticulous history taking, thorough musculoskeletal and neurological examination in any individual presenting with a seemingly benign back pain following a remote isolated episode of seizure, even in the absence of overt trauma. A detailed radiological evaluation guided by a meticulous history taking and detailed clinical examination is essential to rule out a fracture unless proven otherwise. It also shows that a single convulsive seizure can result in a potentially unstable fracture that when neglected, can result in devastating complications like spinal deformity and neurodeficit.Level of evidenceLevel IV.     

Concept Designs of Nonrotating–type Centrifugal Blood Pump and Basic Study on Output Characteristics of the Oscillating Disk–type Centrifugal Pump

Abstract: When designing a turbo–type blood pump as an artificial heart, the gap between a rotating shaft and a pump housing should be perfectly sealed to prevent any leakage or contamination through a seal. In addition, blood coagulation in a blood chamber must be avoided. To overcome these problems, we proposed five different nonrotating–type turbo pumps: a caudal–fin–type axialflow pump, a caudal–fin–type centrifugal pump, a nutating–column–type centrifugal pump, a nutating–collapsibletube–type centrifugal pump, and an oscillating–disk–type centrifugal pump. We selected and developed the oscillating–disk–type centrifugal pump that consists of a disk, a driving rod, a seal, an oscillation mechanism, and a pump housing. The disk is mounted on the end of the rod, which is connected to a high–speed DC motor through an oscillation mechanism. The rod and the disk do not rotate, but they oscillate in the pump housing. This movement of the disk generates forward fluid flow around the axis (i. e., the rotational fluid flow). Centrifugal force due to fluid rotation supports the pressure difference between the outlet and the inlet. The diameter of the disk is 39 mm, the maximum inner diameter of the pump housing is 40 mm, and the volume of the blood chamber for 25 degrees' oscillation is 16. 9 ml. The performance of the pump was tested in a mock circulatory system. Using the disk, in which two holes were bored and a blood chamber designed for 25 degrees' oscillation, output flow rate of 6 and 14 L/min were obtained under motor rotational speeds of 2, 700 and 3, 000 rpm, respectively, at 100 mm Hg mean aortic pressure.     

Chronological changes in the complement system in sepsis

The time courses of serum complement levels and the severity of sepsis were compared in two groups of septic patients, one in which the patients survived (surviving group) and one in which they did not (nonsurviving group). The components of the complement system, namely, C3a, C4a, C5a, CH50, C3, C4, and C5, were measured at several points in time after the diagnosis of sepsis had been established. A 2-antibody radioimmunoassay was used to measure C3a, C4a, and C5a; the latex agglutination test was used to measure C3 and C4; nephelometry was used to measure C5; and Meyer's 50% hemolysis method was used to measure CH50. Following the diagnosis of sepsis, the levels of CH50, C3, and C4 were significantly lower in the nonsurviving than the surviving group, while the levels of C3a and C4a were significantly higher in the nonsurviving than the surviving group. The C5a levels were significantly higher in the nonsurviving than the surviving group, although no significant intergroup differences were subsequently noted. These results suggest that the serum levels of C3a, C4a, C5a, CH50, C3, and C4 could serve as indices of the severity of sepsis. Thus, monitoring the complement system may be useful for predicting the outcome of patients with sepsis.     

Total and free PSA kinetics in patients without prostate cancer undergoing radical cystoprostatectomy

BACKGROUND: Radical cystoprostatectomy and radical prostatectomy are the two major operations where prostate is totally and radically removed. Radical cystoprostatectomy is usually performed in patients with invasive bladder cancer. The aim of the study was to examine Total PSA, Free PSA, and Free/Total Ratio elimination kinetics after radical cystoprostatectomy. METHODS: Serum PSA, Free PSA, and Free/Total Ratio were determined preoperatively, at the time of cystoprostatectomy specimen removal and then at 3, 6, 12, 24, 48, 72, and 168 hr, from seven patients with muscle invasive bladder cancer, who underwent radical cystoprostatectomy. Free and Total PSA concentrations were measured with non-competitive immunological procedures. The elimination rates and half-lives of Total, Free PSA and Free/Total Ratio were studied using a nonlinear regression analysis. RESULTS: Surgical manipulations caused about 1.5-fold increase of PSA, 5-fold increase in Free PSA and 3-fold increase in Free/Total Ratio. PSA and Free PSA followed a biphasic elimination pattern of a rapid exponential (a) phase with a half-life of 4.27 and 2.14 hr and a terminal, nonexponential (b) phase with a half-life of 63 and 173.2 hr, respectively. Free/Total PSA Ratio followed, also, a biphasic kinetic pattern of a rapid exponential decline with a half-life of 3.34 and a terminal non-exponential increase with a doubling time of 43 hr. CONCLUSIONS: Comparing PSA kinetics after radical cystoprostatectomy with those of radical prostatectomy, it appears that PSA follows the same elimination pattern in both models. In contrast, Free PSA and Free/Total Ratio elimination kinetics' patterns differ between the two surgical models.     

Ankle arthrodesis using a modified Masquelet induced membrane technique for open ankle fracture with a substantial osteochondral defect: A case report of novel surgical technique

Reconstruction of a bone defect using the Masquelet induced membrane technique has been well described. However, there are few reports of arthrodesis using this technique. In this case report, we describe a modified Masquelet technique for ankle arthrodesis with nailing. The patient was a 32-year-old man who sustained an open fracture of the right ankle with a substantial osteochondral defect as a result of a fall. Immediately after the injury, a staged procedure using the Masquelet technique was planned. The bone defect was filled with bone cement in the acute stage, but replacement of the cement was needed 6 months after the injury because of a prolonged inflammatory reaction. Ten months after the injury, the bone cement was removed, and ankle arthrodesis was performed using an IM nail with a combination of autologous and artificial bone. As a modification of the Masquelet technique, the anterior surface of the transplant site was covered with a large but thin layer of cortical bone instead of suturing the incised membrane. At 1 year postoperatively, firm bony union was achieved and the implant was removed. At follow-up 3 years after his injury, the patient is able to walk, undertake physical work, and has no clinical signs of infection. Our experience suggests that a modified induced membrane technique may be useful when treating an open limb fracture with an extensive osteochondral defect where preservation of the joint is difficult and arthrodesis is considered.     

Use of a vascularized fibula for spinal reconstruction in neurofibromatosis

We report a case of reconstruction of a dysplasic thoracic spine with vascularized fibula in Recklinghausen's disease. We present the case of a thirteen-year-old lady with neurofibromatosis type 1 who developed a dystrophic thoracic kyphoscoliosis. A T9 compression due to a severe scaloping of the thoracic spine caused an important deformation and a medullar compression (with dorsal pain, right sciatica and a pyramidal syndrome). The surgery consisted in medullar liberation by a T9-T10 corporectomy and an osteosynthesis with arthrodesis T3-L3. A free vascularized fibula bone graft, with an end-to-end anastomosis on a thoracic pedicle, was realized to fill the T8-T11 spinal defect. All the symptoms decreased after surgery and the patient could walk normally few months later. At one-year follow-up the radiographs showed a stable montage and a solid bony fusion. Analysing the literature, vascularized bone graft can be recommended to fill the bony spinal defect due to surgery in cases of tumor, infection, trauma or severe scoliosis. Compared to non-vascularized grafts, which are exposed to resorption, fatigue fracture and then instability, the vascularized fibula grafts provide a rapid fusion, a biomechanically stable and long-standing support with low risks of infection.     

Syndrome de Parkes-Weber et grossesse : implications anesthésiques

We report two deliveries in a patient with a Parkes-Weber syndrome. This parturient had a complex angiodysplasia including a soft tissue hypertrophy of a lower limb, a cutaneous angioma and arteriovenous malformations. The risk of perimedullar arteriovenous malformations was ruled out by angiographic magnetic resonance imaging of the spinal cord. We also describe other aspects of the management, including prepartum cardiovascular assessment, mode of delivery, the use of epidural analgesia and the prevention of haemorrhagia and thromboembolism.     

The Retroperitoneoscopic Repair of a Lumbar Hernia of Petit Case report and Review of Literature

In this paper, we comment on a patient who consulted us because of his «lower backpain» together with the appearance of a small swelling at the left side. Anamnesis and clinical examination were suggestive and further simple diagnostic methods confirmed the exceptional diagnosis of a «lumbar hernia of Petit». We describe the retroperitoneoscopic approach of this hernia, its reduction and the fixation of a polypropylene mesh at the surrounding structures with a Tacker. This approach provided a good postoperative comfort, a shorter hospital stay and an early recovery of autonomy and activity.

Furthermore, we give a review of the literature concerning lumbar hernias and the evolution of the different reconstruction techniques.